Injuries of the Popliteal

Artery Associated with

Fractures and Dislocations

NORMAN W. HOOVER, M.D.

PROGRESS in the surgery of trauma has almost always occurred incidental

to war. Changes of concept in vascular surgery have been no exception.
The uniquely contained operations of the Korean War provided ideal
conditions for application of techniques of arterial repair. The methods
were described in detail by Carrel in 1907. They were thoroughly re-
viewed by Matas in 1921, who reported their extensive use by the
German army during W orld War 1. The limited experience of the Allied
Forces with arterial reconstruction was unsuccessful and influenced
surgeons to disregard the method during World War II. Of 2471 arterial
injuries reviewed by DeBakey and Simeone in 1946, only 81 were re-
paired. The majority of these were simple lateral repairs, and only three
were end-to-end anastomoses by suture technique.
The complacence with which major arteries were ligated arose from
misconceptions of their dispensability. The earlier literature, particularly
Makins'18 widely quoted review of the injuries of World War I, suggested
that many of the major arteries could be sacrificed with relative impunity.
This erroneous conclusion resulted from exclusion from Makins' statistics
of cases in which infection had supervened upon initial ischemia, and
inclusion of ligations for aneurysm. This latter group, in which abundant
collateral circulation had formed prior to ligation, comprised 49 per cent
of his series. The low rate of amputation in Makins' series was refuted
by the statistics of World War II. Reviewing only the cases of acute
traumatic arterial occlusion, DeBakey and Simeone found that ampu-
tation occurred in 49.6 per cent of cases when arterial continuity was not
restored. They concluded that arterial ligation was not a procedure of
choice, but one of stern necessity. The experience of World War II
provided the stimulus for the brilliant successes of the Korean War.
Hughes compiled statistics from several series of arterial injuries treated
by suture repair and found that amputation had ultimately been done
in only 10.8 per cent. There has been no essential change in the tech-
niques described by Carrel. One is left to conclude that the recent success
1099
1100 NORMAN W. HOOVER

with arterial repair has resulted from optimistic and meticulous applica-
tion of methods developed almost a half-century ago.
The ideal applicability of the techniques of arterial repair to civilian
injuries became immediately apparent, and there have been numerous
reports of their use. 8, 12, 22-24, 33 The less destructive nature of most
civilian injuries, and particularly the shorter time within which definitive
treatment can be instituted, predispose them to recovery and make
proficiency in the techniques of vascular repair the obligation of every
surgeon who treats trauma.
While it is recognized that some vessels can safely be sacrificed, the
importance of restoration of blood flow through any major artery is
receiving increasing emphasis. This is particularly urgent in the case of
the popliteal artery. Ziperman reported ligation of this artery in six
patients, of whom three required amputation for avascularity. DeBakey
and Simeone found that amputation followed 72.5 per cent of ligations.
Odom reported loss of 74 per cent of extremities following interruption
of the popliteal artery.
It would now appear that in every patient with evidence of damage
to the popliteal artery associated with skeletal injury, an attempt to
restore arterial continuity is mandatory. Reports of successful repair of
damaged popliteal arteries have appeared with increasing frequency
since the Korean War, when Jahnke and Seeley first noted salvage of
five of seven limbs. In Ziperman's group of 23 repairs of the popliteal
artery, only eight eventuated in amputation.
Civilian experience has been even more promising. Morris and his
associates22 have reported that viability of the limb was preserved in
nine of 11 injuries of the popliteal artery repaired by anastomosis or
graft. Numerous other reports of successful repair in single cases have
appeared.7, 8,25,27

CLINICAL MATERIAL

Twelve instances of injury of the popliteal artery associated with

skeletal trauma form the basis of this report (Table 1). Nine of these
occurred as a result of dislocation of the knee. One resulted from a
crushing injury of the distal part of the thigh, and was associated with
a compound comminuted fracture of the supracondylar part of the
femur. Two resulted from injuries of the proximal part of the tibia.
Nine of the 12 arterial injuries produced ischemia that was incom-
patible with survival of the leg and required amputation within 10 days
of injury. Exploration of the popliteal region was done in seven patients,
and arterial repair in four; injury had occurred at the arterial bifurcation
and was associated with thrombosis of the tibial arteries in the three
instances in which repair was not attempted. None of the four repairs
resulted in ultimate preservation of the leg.
 Table 1. Injuries of the Popliteal Artery
......,
CASE
AGE, YEAR TYPE OF INJURY
INITIAL TRF.ATMENT RESULTS ~
~.
YEARS SEEN
Arterial Skeletal
---
I 36 1912 Transection Compound posterior dislo- Reduction of dislocatiLrll Alll}Jutatiun for gangrene 5 days af[er injury
"
~.

cation of knee ""

~
--- ----
n 71 1928 Contusion; occlusion Dislocation of knee, type'! Reduction of dislocation 1\Ilultipie injuries. Amputation for early gangrene 24 hI'. """
;::,..
by thrombus aft er illj ury
--- ---- '"
!II 62 1942 Unknown; cool pulse-
less leg
Dislocation of knee, type? Open reduction of dislocation Chronic ischenlia with ulceration. Amputation above knee
1 yr. after injury
~
--- ---- ~
".,.
IV 56 1948 Contusion; occlusion Comminuted fracture, prox- Reduction of fracture Leg cool and pulseless, but with fair color 4 days: then be- ~
by thrombus imal tibia came gangrenous. Amputation above knee 9 days after
injury
£.
--- ---- ~
V 23 1949 Contusion; occlusion
by thrombus
Dislocation of knee, type? Reduction of dislocation Pulses present after dislocation; failed after 24 hr. Ampu-
tation below knee "~
--- ---- ~
VI 20 1954 Severance at bifurca- Anterior dislocation. Hy- Reduction. Autogenous vein Circulation restored for 24 hr.; then failed. Amputation
tion perextension graft 1 wk. after injury ~

""""C
--- ----
VII 33 1955 Severance at bifurca- Dislocation of knee, type? Open reduction. Exploration; Foot cool, anesthetic and pulseless. Amputation of great
~
tion repair not possible toe for ischemic ulceration 2 yr. after injury
--- ---- i S·
......
vln Compound, comminuted Internal fixation of fracture.
3 1957 Crush injury at adduc-
tor hiatus fracture, distal femur Crimped nylon arterial
Arterial prosthesis functioned 24 hr.; then failed because of
thrombus. Amputation 10 days after injury '"R.
prosthesis is
--- ---- ".,.

IX 30 1957 Severance at bifurca- Dislocation of knee. Frac- Exploration; repair techni- Progressive ischemia. Amputation, mid-thigh, 12 days after """
;::,..

--- ----
X 13 1960
tion

Avulsion of bifurcation
ture, tibial plateau

Separation of proximal tib-

ial epiphysis. Hyperex-
cally impossible

Reduction. Arterial repair 3

days later with woven teflon
injury. Associated head injury

Circulation improved after reduction; failed 3 days later.

Repair produced no improvement, Amputation below
t
~

~
tension prostheses knee 1 wk. after injury
~---

XI
----
17 1960 Contusion; " spasm"; Posterior dislocation, knee Reduction. E;x:ploration; re- Circulation adequate for 24 hr. after injury; then sudden
"""'"
occlusion by pair technicaJly impossible occlusion. No improvement after decompression. Am-
thrombus putation after 4 m ... for ischemia
--- - - - - Dislocation of knee by hy- Reduction. Fasciotomy; de- Distal pulses restored after repair. E.xtensive muscular
,......
XII 30 1960 Complete transection ,......
perextension bridement. Autogenous vein necrosis produced myoglobinuria. Pulmonary emboli- o,......
graft zation required anticoagulants; amputation for toxicity
and hemorrhage
- - - - -_. __ . - - _._.-
1102 NORMAN W. HOOVER

In Case VI (Table 1) the artery was avulsed at the bifurcation. It was repaired
with a graft from the concomitant vein. Adequate circulation was restored but,
after 24 hours, thrombosis occurred at the distal anastomosis.
In Case VIII the distal portion of the superficial femoral artery and the proxi-
mal portion of the popliteal artery were bridged by a crimped nylon prosthesis.
Circulation failed after 24 hours. The entire prosthesis was found to be occluded
by clot.
In Case X, 4 inches of the artery including the point of bifurcation was severely
damaged from fracture of the proximal tibial epiphysis. Improvement of color
and capillary filling following reduction of the epiphyseal separation caused delay
in exploration for three days even though the leg remained pulseless. When the
circulation failed completely three days later, the artery was repaired with a
teflon prosthesis. Even though the posterior tibial pulse was restored, the mus-
cular ischemia was irreversible and progressed to complete necrosis. The at-
tempted repair was probably unjustified in view of the delay and the extent of
arterial damage. Certainly in retrospect, exploration should have been done
immediately.
In Case XII the patient was first seen 12 hours after complete dislocation of
the knee. The popliteal artery was severed 1.5 cm. above the bifurcation. It was
repaired with an autogenous graft of saphenous vein. The anterior and posterior
fascial compartments were opened widely. The distal pulses were restored and the
arterial repair was technically successful. Myoglobinuria and severe toxicity
developed from extensive necrosis of the calf muscles. Amputation was finally
done as a lifesaving measure, in spite of a patent arterial channel, when pul-
monary embolism occurred. This required anticoagulation, which produced
uncontrollable bleeding from the fasciotomy wound.

Of the nine patients who required early amputation, six showed

immediate evidence of intolerable ischemia. In the remaining three, some
improvement in circulatory status followed reduction of the skeletal
deformity, and only after 24 to 72 hours did obviously incipient gangrene
develop. Each of them, however, in spite of some initial improvement
of color and capillary filling, had a persistently cool and pulseless foot.
It is difficult to say whether the circulatory deterioration was the result
of progressive thrombosis, increasing edema, or ischemia incompatible
with prolonged survival. Delay of exploration was occasioned by unjus-
tified optimism. By our present criteria each of these patients exhibited
indications for prompt exploration. There was a striking difference
between these patients and the two with dislocation of the knee whose
arterial obstruction was immediately and completely relieved by reduc-
tion. It is now apparent, considering the extremely unfavorable outlook
following injury of this type, that anything less than normal circulation
demands immediate surgical attention.
Of the three patients in whom the limb remained viable after obvious
injury of the popliteal artery, two required amputation at a later time
for the sequelae of ischemia. In each of these the foot was cold, pulseless
and anesthetic with recurrence of ulceration. In only one instance did
the foot remain viable and useful. Even this foot was anesthetic and
required amputation of the great toe for ischemic ulceration.
Injuries of the Popliteal Artery Associated with Fractures 1103
Of the 12 arterial injuries, 11 finally resulted in major amputation .
Dislocation of the knee was seen 14 times between the years 1911 and
1960. Injury of the popliteal artery occurred in nine of the 14 patients.
These nine patients constitute the majority of the 12 patients covered in
Table 1. Six of these nine patients required early amputation for gan-
grene; two required delayed amputation, four and 12 months after injury,
for the sequelae of ischemia; and one recovered limited function, as de-
scribed previously. The popliteal space has been explored in every patient
since 1954. Arterial repair was done in two patients but without success
for the reasons described. Arterial trauma was associated with posterior
dislocation in two cases and with anterior dislocation in three; in four
cases the direction of dislocation was not recorded. The only similarity
of the types of injury causing the dislocations was in respect to severity.
The remaining five of the 14 patients with dislocation of the knee
escaped significant arterial injury. Two of these had temporary occlusion
of the popliteal artery, which was completely relieved by reduction of
the dislocation. Three showed no evidence of circulatory disturbance at
any time, though in one the knee remained unreduced for 18 months.
Eight of the 14 dislocations resulted finally in amputation.

ANATOMY

Most injuries of the popliteal artery observed in civilian practice are

caused by dislocation of, or fracture in or near, the knee joint. Arterial
injury in either instance can be related to the peculiar anatomy of the
popliteal region. The popliteal artery (Fig. 1) originates at the tendinous
hiatus of the adductor magnus muscle, by which it is firmly anchored
to the femoral shaft. Within the popliteal space, it gives off five arterial
branches: paired superior genicular, paired inferior genicular and un-
paired middle genicular arteries. These arise immediately above and
below the knee joint and constitute the major collateral system about
the knee. In addition, the communicating system is supplied from above
by the supreme genicular artery and the descending branch of the lateral
femoral circumflex artery. Distally the anastomotic network communi-
cates with the anterior tibial artery by way of the anterior tibial recurrent
artery .
The popliteal artery passes distally between the heads of the gastroc-
nemius muscle and then beneath the tendinous arch of the soleus muscle,
by which it is held firmly against the underlying bone. At this point the
artery ends by division into posterior and anterior tibial arteries, the
latter of which passes immediately through the interosseous membrane.
Although the popliteal artery is moored snugly at either end, it is not
in contact with bone between but is stretched like a bowstring across
the popliteal space. Any distortion of the skeletal anatomy causes
stretching of the popliteal artery. This is particularly true when the
1104 NORMAN W. HOOVER
Descending branch of
lat. fern. circumflex
\ ,.,.Femoral a.
\ /

__ Descending
genicular a.

Lateral
superior....
genicular a. ' -superior
genicular a.

Lateral
inferior- ;i!i'ii"""'"-i"-'<P"
genicular a. .tt!PlfIIIIlillllzlliDrrJ~
Anterior ,,
tibial- Medial
recurrent a. inferior

~,
genicular a.

'.t .. \
tibial a.---1--

Fig. 1. Popliteal and related arteries about the knee. (Reproduced with permission
from Hollinshead, W. H.: Anatomy for Surgeons: The Back and Limbs. New York,
Paul B. Hoeber, Inc., 1958, vol. 3, 901 pp.)

tibia is dislocated anteriorly upon the femur, or when hyperextension

occurs by dislocation of the knee joint or fracture of the proximal part
of the tibia. The latter situation is particularly prone to cause injury
because of the close relation of the arterial bifurcation to the line of
fracture. Arterial rupture tends to occur at the point of emergence of a
major branch, especially if the artery is tethered by passage of the
branch through a fibro-osseous canal, as it is in the popliteal space.
The collateral network about the popliteal artery, scant at best, is
particularly vulnerable because of the dearth of protective soft tissue
about the knee. In the event of dislocation of the knee joint or of widely
displaced fracture, the delicate, poorly protected communicating arteries
between the superior and inferior geniculate rings are likely to be
damaged. Traction injuries of the artery often involve sufficient length
to occlude the origins of either or both genicular systems. Frequently
the injury occurs at the site of bifurcation, leaving only the anterior
tibial recurrent artery as a collateral channel and at the same time
making arterial reconstruction unlikely to succeed.
Injuries of the Popliteal Artery Associated with Fractures 1105
In general, survival of an extremity after injury of a major artery is
related directly to the degree of injury to the surrounding structures,
and consequently to the collateral channels. The structure of the knee
joint is such that dislocation never occurs as the result of trivial injury,
but of an injury that presumes a severe force, causing extensive damage
to the inelastic soft parts about the joint. Association of arterial injury
with fracture has been found to be particularly grave. In Miller's series
of eight patients, seven required amputation. The importance of effective
internal immobilization to the success of arterial reconstruction has
been emphasized. 33 . 36

DISLOCATION OF THE KNEE JOINT

Dislocation of the knee is a rare injury, occurring less frequently than

that of any other major joint. Smillie stated that he had seen only five
such dislocations. Robbins found only one case of complete dislocation
among 150,000 admissions to three general hospitals in Philadelphia.
Our experience at the Clinic supports this incidence; since 1911, 14
dislocations of the knee have been seen among 2,254,162 new admissions.
The low incidence is remarkable in view of the limited contact between
the elliptical femoral condyles and the nearly flat tibial plateaus, which
provide almost no intrinsic bony stability as compared, for instance,
with that of the hip joint. The rarity of dislocation must result from the
extremely strong harness of ligaments and tendons that envelop the
joint.
Dislocations of the knee joint follow no characteristic pattern. They
have been descriptively classified as anterior, posterior, lateral, medial
and rotary.31 Dislocation may occur in any direction, dependent only
upon the direction of the dislocating force. Anterior dislocations result
from hyperextension injuries and comprise about one-half of reported
cases. This lack of pattern suggests that the knee, unlike the shoulder
and hip, has no point of capsular weakness. The significance of these
facts in relation to vascular injury is that it takes an overwhelming
force to dislocate the knee joint, and that the immediate deformity has
invariably been much greater than is present at the time of examination,
when the joint has returned to at least relative alignment. The apparent
deformity therefore cannot be used as an indication of the probability
of rupture of the popliteal artery.
The incidence of injury of the popliteal artery in association with
dislocation of the knee has been variously reported. Watson-Jones noted
only that it may occur. Smillie did not report the number of amputations
among his five cases but observed that amputation through the thigh is
necessary if the popliteal artery is ruptured or thrombosed. Strangely,
Bohler saw 32 dislocations of the knee, but the popliteal artery was
ruptured in only one case, in which the dislocation was posterior. From
1106 NORMAN W. HOOVER

this he concluded that arterial injury is more frequent in posterior than

in anterior dislocation. One can perhaps assume that this series included
lesser injuries than complete dislocation.
Of ten dislocations reported by Ford and Goldner, three resulted in
amputation because of arterial injury. The remaining patients were
found to have adequate peripheral pulses after reduction of the dislo-
cation. In the present series of 14 dislocations, nine patients had arterial
injury; eight of these required amputation and one had persistent
ischemia. Janes has commented on the extremely bad prognosis of knee
dislocation and on the limited success from vascular repair. Perhaps the
paucity of literature on the subject of knee dislocation reflects as much
the bad results of treatment as its infrequency of occurrence.

TREATMENT

Treatment of injury of the popliteal artery requires prompt and

careful management of the patient's general condition. The type of
accident that produces this situation often causes multiple injuries.
Survival of the patient is often in serious question, and it should not be
jeopardized by efforts to preserve the extremity. Loss of blood into the
surrounding tissues, even in the absence of compounding, is usually
sufficient to produce profound shock. The amount of blood delivered to
the limb distal to the injury is dependent not only upon the remaining
collateral capacity but also upon systemic blood volume and pressure.
Therefore, replacement of blood and restoration of blood pressure are
prerequisite to any other definitive treatment.
Treatment of the injured extremity includes use of methods applied
indirectly to promote maximal utilization of the remaining collateral
circulation, as well as use of surgical methods directed toward restoration
of the major arterial flow. The "time lag" between injury and restoration
of circulation is critical. Ideally, circulation should be restored to the
extremity within six or eight hours. However, Jahnke and Seeley pointed
out that duration of ischemia is not the sole determinant of the effective-
ness of treatment. Even a minimal collateral blood supply may prolong
this critical period significantly. The experimental work of Miller and
Welch suggests that some hope of functional recovery exists even after
24 hours of nearly total ischemia. Our experience leads us to believe that
avoidance of delay is much more urgent in injury of the popliteal artery
than in injury of arteries in other regions. We believe, however, that if
the foot is not frankly gangrenous, arterial repair should be attempted
regardless of any delay that has occurred.
In every case of injury to the popliteal artery surgical treatment
should be undertaken immediately. Procrastination in hope of improve-
ment by other means of treatment, or equivocation regarding circulatory
adequacy in a pulseless leg, is indefensible. When the patient's blood
Injuries of the Popliteal Artery Associated with Fractures 1107
pressure has been restored, exploration of the popliteal space is in order.
The Elkin approach offers excellent view of the vessels at the usual site
of injury and permits proximal and distal extension of the exposure
without damage to remaining collaterals.
Arterial injury may be of several types, and the form of treatment will
depend upon the condition of the artery at exploration. Arterial spasm,
particularly in association with fractures, has been noted to produce
distal ischemia. Caution should be exercised in making this diagnosis.
Arterial insufficiency of any severity or duration should not be attributed
to spasm except when confirmed by exploration. Furthermore, the
distinction of arterial spasm from intimal contusion and thrombosis,
even by direct inspection, is often difficult. If an apparently spastic
artery responds promptly to bathing with warm saline solution, 1 per
cent solution of procaine hydrochloride or 2.5 per cent solution of
papaverine, and if normal circulation is restored, the diagnosis can be
accepted. We have not seen this response in the popliteal space.
Contusion of the artery, or severe injury to the intimal and medial
layers without loss of continuity, is the common consequence of traction
injury. Total occlusion of the artery by thrombus formation ensues
within a variable time, requiring excision of the damaged segment of
artery and restoration of continuity by appropriate means. Lacerations
of the artery of a nature that will permit lateral repair seldom occur in
the popliteal region. Complete severance of the artery occurs most often
as the result of traction injury and does not present cleanly lacerated
arterial ends.
The method of repair is dictated by the local conditions. The impor-
tance of adequate debridement of the damaged artery has been stressed
by Jahnke and Seeley who recommend removal of 1 cm. of apparently
normal artery to avoid induction of thrombus formation by minute
injuries of the vessel wall. Such removal is frequently impossible in the
distal popliteal fragment, since injury occurs near the point of bifurca~
tion. In any case, damaged artery should not be conserved to effect
direct repair.
If end-to-end anastomosis is possible after debridement, this is most
likely to be successful. If this is not possible, the best alternative is the
use of an autogenous vein graft. The saphenous vein of the opposite leg
serves better than the concomitant vein because of its size and the
greater thickness of its wall. A vein graft must be reversed to prevent
obstruction of blood flow by its valves. In addition to the attractiveness
of using a living autogenous material, the vein graft has the advantage
of availability and lesser incidence of occlusion than other types of
arterial substitutes. 9 • 16 The method of suture using continuous 6-0
arterial silk has been repeatedly described in the literature.
Arterectomy and ligation as an alternative to repair may be considered
for other arteries, since this procedure produces a partial sympathectomy
1108 NORMAN W. HOOVER

of the distal arterial tree and improves the collateral supply. For the
popliteal artery, this is seldom adequate and should be done only when
(for technical reasons) arterial continuity cannot be restored, as may
be the case when disruption occurs at the bifurcation of the artery.
What to do with the concomitant vein has been discussed since
Makins'17 recommendation that it be deliberately ligated. The rationale
proposed is beyond the scope of the present writing, but it is interesting
that this position was supported by Brooks on the basis of experimental
work, and has been advocated more recently by Linton. The diametric
view, that the vein if injured should be repaired, developed during
World War II. It likely makes little difference what is done. Its repair
probably does not justify the effort, but its deliberate ligation serves
no purpose.
There is invariably an extensive hematoma about the site of popliteal
injury. The inelasticity of the soft parts permits little expansion, and
therefore the pressure undoubtedly contributes to collateral insufficiency.
Ischemia of muscle produces edema which initiates the vicious cycle of
increasing ischemia and edema, resulting finally in contracture. When
arterial flow is restored, muscular edema has been shown to be increased. 30
Therefore, when injury of the popliteal artery occurs, whether or not
repair of the artery is possible, decompression of the hematoma and
extensive fasciotomy are imperative.
The admonition of Janes and Ghormley, "Do not delay; do not
elevate; do not heat; do not refrigerate," is particularly applicable to
injury of the popliteal artery. Adjunctive measures are designed to
improve collateral circulation, to protect the site of repair from thrombus
formation, and to reduce metabolism of the extremity. Arterial spasm
due to injury involves the collateral vessels as well as the distal arterial
system. Lumbar sympathetic block and surgical lumbar sympathectomy
may be of value. Temporary lumbar block done at the time of repair
of the artery has been observed to hasten the circulatory return, thereby
protecting the tissues from prolongation of anoxia. There appears to be
ample clinical evidence of the temporarily beneficial effect of periarterial
sympathectomy by arterectomy as suggested by Leriche and Heitz.
However, this cannot produce total sympathetic denervation, particu-
larly of the collateral channels, since it has been clearly demonstrated
that the majority of postganglionic sympathetic fibers to the arteries of
the extremities reach them through the somatic nerves. 28 • 32. 36 Therefore,
when technical considerations preclude restoration of major arterial
continuity, or when in spite of arterial repair the distal circulation
remains in doubt, lumbar sympathectomy should be seriously considered.
In addition to the surgical measures described, certain adjunctive
measures may be helpful. While the application of heat to the injured
extremity may be deleterious, its application to the abdomen and other
extremities may increase circulation to the injured limb. Intravenously
 Injuries of the Popliteal Artery Associated with Fractures 1109
administered papaverine has been beneficial. Alcohol may be given
systemically as a 5 per cent solution with 5 per cent dextrose in water.
The ischemic limb should under no circumstances be heated, but neither
should it be artificially cooled unless amputation is inevitable. Heparin
is used routinely at the time of arterial repair, by injection of 10 to 20
ml. of 2.5 per cent solution into the proximal and distal portions of the
artery. It has been used by continuous infusion. 12 However, the systemic
use of heparin or other anticoagulants after repair may be hazardous
and is not recommended as a routine.

COMPLICATIONS

The most serious potential complication following an injury of the

type described is that of acute renal tubular necrosis associated with
prolonged muscular ischemia, marked by release of myoglobin and re-
lated blood pigments. This circumstance would be anticipated only after
restoration of circulation following a period of prolonged ischemia. In
this series, release of gross amounts of pigments into the urine occurred
in only one patient in whom arterial continuity was restored. Renal
function was not seriously impaired. Consideration has been given to
irrigation of the extremity for a period prior to restoration of circulation
in order to diminish the amount of muscle pigment released into the
general circulation and imposed upon the kidneys.
Prevention of gangrene is not the sole desideratum of arterial repair.
Collateral circulation about the knee is such that the lesser sequelae of
ischemia such as trophic skin change, hyperalgesia, claudication and
recurrent ulceration can be predicted to occur after traumatic interrup-
tion of the major circulation. A case can therefore be made for repair
of the popliteal artery even though the viability of the foot is not
threatened.
Contracture of the muscles of the calf following injury of the popliteal
artery has frequently been observed. This has the characteristics of
Volkmann's ischemic contracture. Muscular necrosis is often found to
be more extensive than the superficial appearance of the limb would
indicate. After restoration of arterial continuity, even though viability
of the limb is assured, progressive muscular contracture may occur. This
is more easily managed in the lower extremity than in the upper, and the
apparent ischemia of the muscles of the calf should not deter efforts to
save the limb.
Combined injuries involving the nerves of the popliteal region present
a special problem. 13 Sensory disturbance and paralysis may result either
from concomitant injury of the tibial and perineal nerves or as a result
of ischemia. Although a pure nerve lesion is easily recognized, it may be
difficult to distinguish a pure arterial injury from one involving the
nerves as well. This is, of course, of prognostic significance since an
1110 NORMAN W. HOOVER

anesthetic foot is extremely troublesome even though vascular recovery

is complete. The popliteal nerves are not anatomically fixed as the
arteries are, and therefore are less likely to become severed. Hence,
injuries of the nerves are usually traction injuries in continuity, from
which some recovery may occur. Their surgical repair may await deter-
mination of spontaneous recovery.
Closed reduction of dislocation of the knee joint may sometimes be
precluded by interposition of joint capsule or hamstring tendons. Open
reduction can be combined with arterial exploration. Instability of the
knee joint invariably follows complete dislocation, though in most
instances acceptable function can be obtained by six weeks of immobili-
zation and a period of exercise for strengthening of the quadriceps mus-
cle. If excellent vascular recovery follows arterial repair, one might
properly consider repair of the ligaments of the knee joint at a later time.

SUMMARY AND CONCLUSIONS

Traumatic occlusion of the popliteal artery associated with skeletal

injury was seen in 12 patients at the Mayo Clinic between the years
1911 and 1960. Three of these were associated with fractures of the
distal part of the femur and proximal part of the tibia. Nine resulted
from dislocation of the knee joint.
Dislocation of the knee occurred 14 times during the same time
interval, and accounted for the majority of vascular injuries in this
series. Five of the dislocations caused no vascular injury.
Occlusion of the popliteal artery complicating skeletal injury portends
a grave prognosis. Of 12 arterial injuries, all resulted in significant
ischemia. Gangrene occurred in nine, requiring early amputation. In
two amputation was required at a later time for effects of chronic vascu-
lar insufficiency, and in one the surviving limb was subsequently cool
and anesthetic.
Vascular impairment of any degree following skeletal trauma in the
region of the knee indicates prompt exploration and, whenever possible,
restoration of major arterial flow by anastomosis or graft repair. Tech-
nical considerations will sometimes preclude reconstruction of the artery,
but this can be determined only by exploration.
Success of arterial repair, both in restoring circulation and in avoidance
of the sequelae of ischemia, depends upon prompt operation. Technical
success in two cases failed to preserve the extremity because of the
effect of prolonged anoxia. Loss of time is often avoidable and frequently
results from hopeful delay. However, "time lag" in excess of the ideal
does not totally preclude a favorable outcome and should not contra-
indicate attempted surgical repair.
Survival of the extremity is not the only aim of arterial repair. The
consequences of chronic circulatory deficiency may also be avoided.
1 Injuries of the Popliteal Artery Associated with Fractures 1111
Every patient who does not have normal circulation after reduction of
skeletal qeformity should have immediate surgical exploration of the
popliteal space in an effort to restore the integrity of the popliteal artery.

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